374600589-10-9-2023-18-AS-JSRS-CWG2UR-20231009174245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374600589
Report Date: 10/09/2023
Date Signed: 10/09/2023 05:42:51 PM

Document Has Been Signed on 10/09/2023 05:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	TWIN OAKS GARDEN		FACILITY NUMBER:	374600589
ADMINISTRATOR:	SNEZANA LUKIC		FACILITY TYPE:	740
ADDRESS:	1965 EDWIN LANE		TELEPHONE:	(760) 471-8704
CITY:	SAN MARCOS	STATE: CA	ZIP CODE:	92069
CAPACITY:	6	CENSUS: 5	DATE:	10/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Snezana Lukic, Administrator		TIME COMPLETED:	05:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA met with Snezana Lukic, Administrator, and discussed the purpose of the visit. The facility is licensed to serve six (6) elderly residents, all of whom may be non-ambulatory. A Hospice waiver is approved for three (3) residents. A tour of the facility was conducted inside and out. At the time of visit, there were five (5) residents home and one (1) staff was available. The facility consist of two (2) housing structures that contain three (3) bedrooms and one and one half (1-1/2) bathrooms in the main house, and a three (3) bedrooms and two and one half (2-1/2) bathroom in the second house. The laundry room is also located in the second structure. During the tour the following was observed: Resident bedrooms had the required furnishings and were observed to be in good condition. Bathrooms had required signage, hand rails, non-slip mats. Night-lights were observed in the hallways. Fixtures and furniture for an operational facility are present and in good repair. All passageways were free of obstructions, charged fire extinguishers and the fire alarm system was operable, medications are kept centralized and locked, hazardous items are kept inaccessible clients. Hot water was tested at 114 degrees Fahrenheit. Backyard area is free from obstructions. Kitchen/Food Service: LPA observed the entire kitchen, food is stored properly and dishes are clean and in good condition. There is a sufficient supply of perishable and non-perishable foods. Area was observed to be clean and functional. Care & Supervision: Facility has sufficient care staff employed. Administration: Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility. Drills are conducted quarterly. The last drill was conducted on 10/1/2023.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: TWIN OAKS GARDEN	FACILITY NUMBER: 374600589
	VISIT DATE: 10/09/2023

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Record Review and Client/Staff Files: LPA reviewed current staff and all staff have Criminal Background Clearance, current CPR/First Aid certification, and trainings are current. Resident records were reviewed and contained required documents. All resident documents were current and up to date.

Medication Review: LPA reviewed medication and medication appears to be dispensed according to Physicians orders.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

A copy of this report was provided to Administrator, Snezana Lukic.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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